Provider Demographics
NPI:1841301728
Name:SHOUSHTARI, BABAK (DMD)
Entity type:Individual
Prefix:DR
First Name:BABAK
Middle Name:
Last Name:SHOUSHTARI
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4150 REGENTS PARK ROW
Mailing Address - Street 2:SUITE 330
Mailing Address - City:LA JOLLA
Mailing Address - State:CA
Mailing Address - Zip Code:92037-9124
Mailing Address - Country:US
Mailing Address - Phone:858-546-9299
Mailing Address - Fax:858-546-9399
Practice Address - Street 1:4150 REGENTS PARK ROW
Practice Address - Street 2:SUITE 330
Practice Address - City:LA JOLLA
Practice Address - State:CA
Practice Address - Zip Code:92037-9124
Practice Address - Country:US
Practice Address - Phone:858-546-9299
Practice Address - Fax:858-546-9399
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-31
Last Update Date:2016-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA475621223E0200X
CADDS475621223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223E0200XDental ProvidersDentistEndodontics